STATE OF NEW JERSEY
PAYMENT VOUCHER
(INVOICE)		MACSE
DOCUMENT NUMBER		ACTG
PER	FY	
			     		     	    	
							
		PP START	SCHED PAY	CHK	OFF	F	RF	CK	(A) VENDOR
ID NUMBER	
		MO	DY	YR	MO	DY	YR	CAT	LIAB	A	TY	FL		
	PV DATE
     	  	  	  	  	  	  	  	  	 	  	  	     	
Agreement Date (B)	Agreement No. (B)	Contract ID # (B)	PAYEE:	SEE INSTRUCTIONS FOR
	COMPLETING ITEMS
	(A) THROUGH (H)	C	TOTAL AMOUNT	
     	     	     		     	
(D)	PAYEE NAME AND ADDRESS
     	(E)	SEND COMPLETED FORM TO:
     	
(F)	PAYEE DECLARATIONS
I CERTIFY THAT THE WITHIN PAYMENT VOUCHER IS CORRECT IN ALL ITS PARTICULARS.  THAT THE DESCRIBED GOODS OR SERVICES >> >> >> 
HAVE BEEN RENDERED AND THAT NO BONUS HAS BEEN GIVEN OR RECEIVED ON ACCOUNT OF SAID DOCUMENT		
(F)		PAYEE SIGNATURE	
(F)		     		     	
(F)		PRINT PAYEE NAME/ TITLE		DATE	
LINE NO	REFERENCE		 (G)	PAYEE REFERENCE NUMBER	
1	O/R	AGY	FAO/FRA # 	LINE		
	     	     	     	     	     	
2	     	     	     	     	     	
3	     	     	     	     	     	

1	FUND	AGCY	ORG CODE	APPR UNIT	ACTIVITY CODE	OBJECT CODE	CFS PROJECT #	REPT CATEGORY	
	     	     	     	     	     	     	     	     	
2	     	     	     	     	     	     	     	     	
3	     	     	     	     	     	     	     	     	

1	ACCOUNTS PAYABLE REFERENCE #	AMOUNT	I/D	
	     	     	  	
2	     	     	  	
3	     	     	  	

COST INCURRED
DATES (H)	CONTRACT DESCRIPTION (H)	AMOUNT	
     	     	     	
     	     	     	
     	     	     	
     	     	     	
     	     	     	
     	     	     	
     	     	     	
	TOTAL	     	
CERTIFICATION BY RECEIVING AGENCY:  I certify that the above 
services have been rendered in accordance with the contract agreement.		CERTIFICATION BY APPROVAL OFFICER:  I certify that this Payment Voucher is correct and just and payment is approved.	
			
Signature		Authorized Signature -Accounting	
     		     		     		     	
Print Name/Title		Date		Print Name/Title		Date	
PV (C) 6/08

PAYEE INSTRUCTIONS – PV (C)
SHADED AREAS (A - H) ARE REQUIRED TO BE COMPLETED BY PAYEE

A)	VENDOR IDENTIFICATION NUMBER
  Complete the payee identification field with the federal employer identification number
  assigned to the business or the social security number if the payee is an individual.	
	  NOTE: You must be registered with the State of New Jersey Department of Treasury in     
  order to receive payment.	
		
B)	CONTRACT INFORMATION
  Contract Agreement date, Agreement Number assigned within contract and Contract I.D.# 
  are in the Executed Contract Agreement.	

C)	TOTAL AMOUNT
  Enter the total amount of this payment voucher.	

D)	PAYEE NAME AND ADDRESS
  The name of the individual or company to whose name the check shall be drawn and 
   the complete address where the check shall be mailed.       	

E)	SEND COMPLETED FORM TO:
  Division or Bureau to whom the services were furnished. Forward 2 copies of the invoice 
  to appropriate Contract Manager as noted in the Executed Contract Agreement.     	

F)	PAYEE DECLARATION
  Payee must sign the declaration and date the payment voucher.
  Print name and title.	

G)	PAYEE REFERENCE NUMBER
  Payee must show its own invoice or billing number or any other identification for     
  reference purposes. This information is recorded on the check stub and aids the
  payee to identify the invoices which have been paid. Do not use more than 
  30 characters and must be unique.	

H)	COST INCURRED DATES AND CONTRACT DESCRIPTION
Cost incurred dates and description of work performed, including task order number or extra work modification number, UPC Code if available.	

		
		
TO INSURE PROMPT PAYMENT, SEND COMPLETED PAYMENT VOUCHER PV (C), WITH   
SUPPORTING SUMMARIES AND PROGRESS REPORT. BE SURE TO INCLUDE 
PAYEE SIGNATURE. 	

		
VENDORS MAY BE ENTITLED TO INTEREST ON PROPERLY EXECUTED SUBMITTED PAYMENT VOUCHERS THAT ARE PAST THE STATE OF NEW JERSEY’S DEADLINE FOR ELIGIBLE STATUTORY PROMPT PAYMENT INTEREST.